Case Report - (2023) Volume 18, Issue 1
Received: 21-Dec-2022, Manuscript No. gpmp-22-84391; Editor assigned: 22-Dec-2022, Pre QC No. P-84391; Reviewed: 29-Dec-2022, QC No. Q-84391; Revised: 10-Jan-2023, Manuscript No. R-84391; Published: 30-Jan-2023
Aim: This case reports a patient of postpartum partial HELLP (hemolysis, elevated liver enzymes and low platelets) who manifested rectus sheath hematoma after 5 days of cesarean section (CS) and we shortly summarize HELLP syndrome, its diagnosis and treatment.
Case: A pregnant woman (G2P1, 38 weeks) visited us due to headache and high blood pressure (BP) with urine protein 3+: with blood count, coagulation, and liver enzymes being normal. Cesarean section (CS) was performed, after which MgSo4 was administered. BP was stabilized; then, post-CS day 2, platelets began to decrease with elevated lactate dehydrogenase with small drop of hemoglobin. Post-CS day 3, drop of hemoglobin, decreased platelets count and elevated LDH were observed, which made us diagnose this condition as partial HELLP (liver enzymes were normal). Post-CS day 5, she complained of lower abdominal pain and bilateral lower abdominal swellings at site of CS scar. Ultrasound revealed bilateral rectus sheath hematoma, which was confirmed by CT. Hb was 8.7 gm/dl, so 2 units of packed RBCs were transferred. She was kept on triple antibiotics together with antihypertensive drugs and was discharged 12th day post-CS. Laboratory data returned normal, indicating resolution of partial HELLP syndrome. Three months post-CS, hematoma disappeared.
Conclusion: Obstetricians must be aware that HELLP/partial HELLP can occur after successful CS and rectus sheath hematoma can manifest.
Preeclampsia; Partial HELLP syndrome; Rectus Sheath hematoma; Conservative management; Case report
HELLP syndrome was first assigned by Weinstein in 1982. It is a rare complication of hypertensive disorders of pregnancy and represents the severe end of the spectrum of pre-eclampsia [1]. HELLP syndrome is defined by the presence of all of the three following criteria: hemolysis (characteristic peripheral blood smear, serum lactate dehydrogenase ≥ 600 U/ l, total serum bilirubin ≥ 1.2 mg/ml), elevated liver enzymes (serum aspartate aminotransferase ≥ 70 U/l), and low platelet count (< 100,000/μl). Partial HELLP syndrome (PHS) was defined by the presence of one or two features of HELLP syndrome but not the complete syndrome. Partial HELLP has lower incidence than HELLP syndrome and was described in many studies but is not as severe as HELLP syndrome. Postoperative HELLP syndrome can have serious sequel but occurrence of Partial HELLP post-operative is not usual, but it seems that it may cause same complications as complete HELLP syndrome [2].
The patient is P1 CS pregnant at 38 weeks gestation with regular follow up, she came to the emergency department complaining of headache and bilateral Lower limb edema. The blood pressure was 160/100 mm hg, albuminuria +3 by dipstick. Abdominal examination revealed fundal level of 36 weeks, with no uterine contractions, vaginal examination revealed closed cervix and low bishop score. The laboratory tests were reassuring with normal hemoglobin, platelets, and normal coagulation profile, normal ALT, AST and LDH. The patient was transferred to delivery room and management began with antihypertensive treatment and loading MgSO4 administration with usual protocol, after controlling blood pressure and patient gave her consent to perform CS as she refused TOLAC. The consultant on call performed the CS. There were no intraoperative complications except for mild adhesions. A drain was left intraabdominal. After CS, the patient was transferred to the ward with her antihypertensive and MgSo4 which was stopped after 24 hours. According to our hospital protocol, complete lab investigations are performed routinely every day for preeclamptic patients till discharge, the patient hemoglobin began to decrease, platelets began to drop postoperative, liver ALT and AST stayed in normal range, LDH was rising. Partial HELLP (all criteria but normal Liver enzymes) was diagnosed on 4th day post-CS (on day before development of hematoma).
The primary consultant and the surgeon consultant decided to keep the patient in hospital to follow up the abnormal laboratory findings. Fifth day postoperative, the patient complaint of sudden lower abdominal pain, on examination bilateral swelling was felt at both sides of CS scar. Immediate abdominal ultrasound was done revealing bilateral hematomas 8 × 8 cm and 8 × 6 cm. CBC was done revealing Hemoglobin 8.7 mg/dl, 2 units of Packed RBCS were transferred to the patient. CT was done to confirm the nature and exact site of hematomas, CT revealed bilateral rectus haematoma rt side 8 × 6.7 cm and lt side 8, 7 X 6 cm (Fig. 1. 2. and 3. Tab. 1.).
Fig 1. CT Sagittal sections of bilateral rectus sheath hematoma.
Fig 2. CT Coronal sections of bilateral rectus sheath hematoma.
Fig 3. CT Axial sections of bilateral rectus sheath hematoma.
| Day | Hemoglobin gm/dl | Platelet x 100,000 |
ALT IU | AST IU | LDH IU |
|---|---|---|---|---|---|
| CS DATE | 10.7 | 160 | 31 | 42 | 416 |
| 1st day post-op | 10.3 | 150 | 37 | 46 | 483 |
| 2nd day post-op | 9.8 | 138 | 39 | 48 | 550 |
| 3rd day post op | 9.5 | 135 | 37 | 46 | 600 |
| 4th day (partial HELLP was Diagnosed and decision for conservative management |
9 gm * | 120** | 33 | 46 | 616*** |
| 5th day post-op day of hematoma | 8.7 * 2 units of packed RBCS |
100** | 39 | 40 | 800*** |
| 6th day after 2 packed RBCS | 10 | 150 | 37 | 35 | 815** |
| 12th day One week after hematoma with conservative management |
11 | 170 | 37 | 39 | 400 |
Tab. 1. Lab investigations from admission till discharge with management done.
Both consultants agreed on conservative management and to keep the patient in hospital; IV triple antibiotics were prescribed. The patient was hospitalized for 3 days after daily CBC, coagulation profile and liver and kidney functions. Ultrasound before discharge was done revealing organization of both hematomas. The patient was discharged on the fourth day (after discovery of hematomas). She was instructed to come weekly in the outpatient clinic. The patient was followed in outpatient clinic every week in first month after discharge till organization of hematoma. In each follow up visit during the first month, size of hematomas was assessed clinically and by abdominal US. After 3 months, the patient swelling disappeared and the swelling was resolved.
The common features of rectus sheath hematoma (RSH) include fever, acute abdominal pain, nausea and vomiting, while in the present case; the patient complained only of abdominal pain. The non-specific nature of the symptoms combined with the low incidence of this complication lead to difficulty in diagnosis. RSH is usually caused by local trauma to inferior epigastric vessels, coagulopathies, hypertension, HELLP and Partial HELLP [3]. The usual way of diagnosis is by ultrasonography and CT scan [4]. In a study of Joshi and Upadhyaya, three patients presented with rectus sheath hematomas, all were post CS. ultrasonography and MRI were used to confirm the diagnosis. The patients were managed with surgical exploration and hematomas drainage [5].
In a case report reported by Ansar MJ, et al., [1], they had rectus sheath hematoma and subcapsular liver hematoma in a patient 25-year-old G2 P1 at 32 weeks of gestation diagnosed with eclampsia and HELLP syndrome. Post CS, the patient developed hypotension and oliguria. Ultrasound revealed free fluid in peritoneal cavity. Exploratory laparotomy was done 12hrs after LSCS. There was rectus sheath hematoma was about 6 cm and liver capsular bleeding was present from liver surface. Liver packing was done with 6 units of Fresh frozen plasma; four units of packed RBC were transfused. Patient was transferred to ICU postoperatively. Patient developed acute renal failure with hyperkalemia which led to cardiac arrest. This case report is far more severe than our case because it was accompanied by liver capsular hematoma which ruptured uneventfully leading to death of the patient.
HELLP syndrome is known to cause a variety of postoperative complication and this case proves also that Partial HELLP is as serious as complete HELLP. Another strength point is conservative management after hematoma discovery and no rush for surgical evacuation.
Review on hellp and partial hellp syndrome
About 70% of the cases of HELLP syndrome occur antenatal and within 48 hours postnatal. Women with postpartum HELLP syndrome have higher incidences of complications, such as pulmonary edema, renal failure, disseminated intravascular coagulation, and subcapsular liver hematoma [6,7].
Since Bahaa El-Sibai proposed strict criteria for the diagnosis of the (true HELLP syndrome) it has been observed that many patients with severe preeclampsia may have isolated laboratory abnormalities such as hemolysis or low platelet count or elevated liver enzymes, without the complete HELLP syndrome. Women with partial HELLP syndrome (PHS) should be studied and managed separately from women with HELLP syndrome or severe pre-eclampsia. The incidence of HELLP syndrome is 2 to 12%, while the incidence of PHS is unclear [8,9].
Risk factors
High body mass index, metabolic disorders as PET, as well as antiphospholipid syndrome, significantly increase the risk of HELLP syndrome in all women [10].
Classification
The Mississippi classification system is based on maternal platelet count as a primary indicator where class I HELLP syndrome is considering platelet count less than 50,000/μl, class II the platelet count more than 50,000/μl but less than 100,000/μl and class III platelet count more than 100,000 and less than 140,000/μl, together with hemolysis and elevated liver enzymes levels [7]. Tennessee classification system is based on the partial or complete of HELLP syndrome [11]. In Complete HELLP, serum LDH level is more than 600 IU/L, platelets counts less than 100,000/μl, and serum AST levels is more than70 IU/L. while Partial HELLP would have only one or two of the features of the platelets, liver enzymes or LDH [12].
Pathophysiology
The pathophysiology shares a common mechanism, which is endothelial cell injury [13]. Following endothelial injury, vasospasm and platelet activation occur together with the decreased release of the endothelium-derived relaxing factor (EDRF) and increased release of von Willebrand factor (VWF) [14]. This leads to general activation of the coagulation system and inflammation [15].
Clinical diagnosis and investigations
Symptoms usually develop in the third trimester, second trimester or postpartum is also possible. The most common symptom is abdominal pain and tenderness in the right upper quadrant, epigastrium, or below the sternum. Hypertension where blood pressure ≥ 140/90 mmHg and proteinuria +2 or more are present in approximately 85% of cases [16]. The Lab diagnosis of HELLP syndrome is based on presence of microangiopathic hemolytic anemia, increase liver enzymes, and thrombocytopenia in women suspected to have preeclampsia [12]. Thrombocytopenia is the main and earliest defect that is present in all patients with HELLP syndrome. When the platelets count is less than 50,000/μl, tests such as FDPs (fibrin degradation products) and antithrombin III activity can alert the presence of an on-going disseminated intravascular coagulopathy (DIC) [10]. Liver dysfunction is characterized by elevated serum alanine and aspartate transaminases, and elevated LDH [12].
Differential Diagnosis
HELLP syndrome and Partial HELLP should be differentiated from acute fatty liver of pregnancy, hepatitis, idiopathic thrombocytopenic purpura, hemolytic-uremic syndrome and antiphospholipid syndrome [16].
Treatment
When the HELLP or Partial HELLP syndrome is diagnosed, the main priority is to assess and stabilize the patient’s condition, especially coagulation defect. Thereafter, fetal assessment should be evaluated by ultrasound biophysical profile, umbilical artery doppler and CTG [11]. A decision needs to be made as to whether immediate termination of pregnancy where there is no role of conservative management. The patient with evidence of preeclampsia and right upper quadrant pain and nausea must be evaluated to rule out HELLP syndrome. The acceptable opinion for severe cases is that to control hypertension and immediate delivery, usually by emergency caesarean section, is the treatment of choice [17].
Antihypertensive drugs (labetalol, hydralazine or nifedipine) are used to treat severe hypertension while Magnesium sulphate is given intravenously to prevent convulsions [18].
HELLP syndrome can be manifested in the postpartum period or worsen after delivery. Blood pressure must be controlled and magnesium sulphate is continued for 48 hours. Postpartum corticosteroids can be used to resolve the HELLP syndrome [19].
Obstetricians must be aware that partial HELLP can occur after successful CS and rectus sheath hematoma can manifest.
Verbal consent was taken from the patient to publish the case report; no IRB approval is needed in this case as she was a private case in private hospital
CD of the CT is available upon request.
The authors report no conflict of interest.
No Financial support for this case report.
Not applicable.
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